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.Jun 1,6 09 11 : 43a Jeff Kindorf 2098207818 p. 4 Please print or type.(Form designed for use on elite(12-pitch)typewriter.) I Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS i.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number` ty . WASTE MANIFEST JJK ' �- 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) i I i I Generator's Phone: 6.Transporter 1 Company Name U.S.EPi 0 Number 7,Transporter 2 Company Name U.S.EPA ID Number I B.Designated Facility Name and Site Address U.S.EPA ID Number I Facility's Phone: ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number. 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity, Wtivol. I w f L 2. I 3. 1 I ; i I ( 4. I I � 14.Special Handling Instructions and Additional Information i 15. GEN ERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and labeledfplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary Exporter,,certify that the contents of this consignment oonform to the terms of the attached EPAAcknowledgment of Consent. l certify that the waste minimization statement identified in 40 CFR 262.27(x)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. Generator'slOfferor's PrinledlTyped Name Signature Month Day Year J 116,International Shipments ❑Import to U.S. ❑Export from U.S. Port of entry/exit: z Transporter signature(for exports only): Date leaving U.S.: rx17.Transporter Acknowledgment of Receipt ofMalerials Li Transporter Printed/Typed Name Signature Month Day Year O CL W Month a Year z Transporter Printed/Typed Name Signature y Q � I 1� 18.Discrepancy 18a.Discrepancy Indication Space ❑Full Re ❑ Quantity El Residue ❑Partial Rejection jection Manifest Reference Number. F� 18b.Alternate Facility(or Generator) U.S.EPA 10 Number J U Facility's Phone: Month Day Year 1 Be.Signature of Alternate Facility(or Generator) �Q LU Z h19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment•disposal,aril recycling systems) j w1 2. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 1 Be Printed/Typed Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. P,.A :;ro'S